DSM-5 – Are We All Nuts?

That may not sound so bad, but the implications of being diagnosed with a mental disorder, when actually the symptoms you are experiencing are no more (and no less) than a perfectly normal reaction to everyday, at times very tough, life, can be very serious. Over-diagnosing can cause unnecessary stress and anxiety, having to deal with stigma, and taking potentially dangerous medication.

The new edition of the American book of psychiatric diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, published in May 2013, has triggered immense controversy and harsh criticism among psychiatrists, psychologists, pharmaceutical experts and others.

Before I continue, I would like to mention that I have no formal education in any medical field and that I personally have not read the DSM-5. My interest in mental health and illness stems from my being a mother of a 24-year-old coping with OCD and schizophrenia. The article “The Psychiatrists’ Bible or a Formula for Overdiagnosis?” (Hebrew) by Yaffa Shir-Raz, Menta Magazine (Israel), Issue 155, August 2013, inspired me to compile this paper. From the article I picked relevant parts and translated and adapted them. I added quotations and links from various additional sources, and topped it all with a few lines drawing on my own thoughts and experience.

Diagnosing mental illness is often a tricky and highly complex business. Mental disorders cannot be detected by means of a blood test, ultrasound or MRI (at least not at the present state of available research data. Here’s more info on that point: “The DSM-5 controversy. Tablets from Mount Sinai; a step backward or the natural progression of advances in medicine?”, Charles B. Nemeroff and Daniel Weinbergerhttp://www.biomedcentral.com/1741-7015/11/202). The diagnosing health care provider thus mainly relies on observation and questioning of the patient, combined with his own experience. Medical tests may be necessary to rule out physical causes of the symptoms. Social, cultural and environmental factors need also to be considered, as they are an important part of the surroundings influencing a person’s feelings, thoughts, and behavior. Another decisive aspect is whether the patient is hospitalized, which enables observing him 24 hrs a day, or if he/she is an out-patient, thus limiting the doctor to relatively short, interrupted sessions with him/her.

In the case of my son, I only recently found out why he was nearly released from the hospital without having received a proper diagnosis (and thus no treatment, which would have ended in a catastrophe): He told me that in the beginning of his hospitalization he did not tell the medical staff about his delusions and irrational fears, because he believed that talking about them would make them come true. So he hardly said anything although he was suffering like hell. Finally though, a different psychiatrist took over the treatment and together with the help of a good friend and former therapist of my son who helped him become comfortable about sharing his thoughts, diagnosis of schizophrenia was established. This is just one example of how catchy diagnosing mental disorders can be, and of how much treating doctors depend on the cooperation of the patients.

The main points of criticism in a nutshell

“Allen Frances, MD, who chaired the DSM-IV Task Force and is among the DSM-5’s staunchest critics, told Medscape Medical News that he is filled with ‘sadness and worry — and I am not a person usually given to either emotion.’

He added that he is very concerned that the “DSM 5 will result in the mislabeling of potentially millions of people who are basically normal. This would turn our current diagnostic inflation into hyperinflation and exacerbate the excessive use of medication in the “worried well”.’ ”

“ ‘DSM-5 turns grief into Major Depressive Disorder; temper tantrums into Disruptive Mood Dysregulation; the expectable forgetting of old age into Mild Neurocognitive Disorder; worrying about illness into Somatic Symptom Disorder; gluttony into Binge Eating Disorder; and anyone who wants a stimulant for recreation or performance enhancement can claim Attention Deficit Disorder,’ he said.”

“Dr. Frances also expressed concern that the new manual will divert scarce mental health care resources away from those who need it most.

‘While we are overtreating people with everyday problems who don’t need it, we are shamefully neglecting the people with moderate to severe psychiatric problems who desperately do.’

His advice to frontline clinicians regarding the DSM-5?

‘Don’t buy it, don’t use it, don’t teach it.’ ”

“Dr. Frances is not alone in his criticism of the manual. An April 29 blog post by Thomas Insel, MD, director of the National Institute of Mental Health (NIMH), and published on the NIMH Web site stated that although the upcoming manual is reliable, it lacks validity.

As reported by Medscape Medical News at that time, Dr. Insel pointed out that unlike diagnostic criteria for other diseases, the DSM-5 criteria are based on consensus rather than objective laboratory measures, and he noted that the NIMH will be ‘re-orienting its research away from DSM-5 categories.’ Toward that end, Dr. Insel went on to announce the launch of the NIMH Research DomainCriteria (RDoC) in a first step toward ‘precisionmedicine.’ ” http://www.medscape.com/viewarticle/804410

Some of the disputed changes in more detail

Coffee WithdrawalHave you decided to stop drinking coffee and are experiencing headaches and extreme tiredness? Well, according to the new DSM you are suffering from a mental disorder: The Caffeine Withdrawal Syndrome.

Age-Related ForgetfulnessAre you older and suffering from a forgetfulness that is normal for your age? You might find it interesting to learn that from now on you are categorized as suffering from Mild Neurocognitive Disorder.

Combination of Autism Spectrum Disorders into Single Category“One of the most publicized changes in the DSM-5 involves grouping all of the subcategories of autism into a single category known as autism spectrum disorder (ASD). This move effectively eliminates previously separate diagnoses of autism – including autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive development disorder “not otherwise specified” (PDD-NOS).

DepressionDepression is one of the areas in which the abundance of syndromes is controversial. Dr. Frances stated in an interview that the DSM staff groups Major Depressive Disorder, which completely impairs the ability to function and requires medical treatment, together with cases of light depression that may just be the natural reaction to everyday life. As a result, he says, and due to the wrong allocation of funds, people suffering from serious depression are not treated sufficiently while at the same time those who don’t really need it receive medication against depression to handle problems that will most probably solve themselves. In the center of criticism is the “Depression connected to Grief”.

BereavementIf you have lost a close person and are going through a grieving period in which you typically lack appetite and are having trouble sleeping, you are entitled to the diagnosis of Major Depressive Disorder from the very first day of bereavement. While the previous editions of the DSM recommended refraining from diagnosing depressive disorders in grieving people during the first two months following death, the present edition enables such a diagnosis right from the start.

In his book “Medication Madness, The Role of Psychiatric Drugs in Cases
of Violence, Suicide and Murder” the psychiatrist Dr. Peter Breggin says that depression is a normal reaction in people who have lost a close person and that it is a mistake to treat it with medication. Many experts agree with this view and criticize the DSM-5, saying that the change is part of a phenomenon called medicalization.

“Medicalization isn’t the most elegant noun…but it’s the best one we have for describing how common emotions and traits are turned into treatable conditions. Bad breath becomes halitosis, for example, and impotence erectile dysfunction. Even overdoing plastic surgery gets a brand-new name: body dysmorphic disorder. To put it bluntly, this process of pathologizing has gotten out of control. It’s become a juggernaut that no one seems able to stop.” http://harvardmagazine.com/2009/04/medicalization-of-our-culture

“Mourning traditions have been known since ancient times and in Judaism these traditions are strongly expressed in the ceremonies and rituals of the Shivah, the Shloshim, and the First Year; and the gradual return to life.” says Prof. Shaul Schreiber, head of the psychiatric division and psychiatric day-care unit at the Tel-Aviv Sourasky Medical Center. Prof. Schreiber continues: “The new DSM now determines that medication should be administered already at the grave, immediately after the person has buried his loved one. But if the person is not really ill, medication will not help him and will not improve his feeling or his way of coping. Cases of pathological grief obviously necessitate treatment, but such cases are rare. Should we treat all the other grievers under the banner of these few exceptional cases? According to the Israeli Central Bureau of Statistics, there are about 50 thousand deaths per year and every deceased has several close relatives. The implication of this is that there is an enormous potential market of medication users.”

Disruptive Mood Dysregulation Disorder“DSM 5 will turn temper tantrums into a mental disorder – a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads – a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.”

“Temper tantrums at least three times a week? Wow! How about three times a day or more. Many, many children, as part of the learning process, seek to ‘push the envelope’ when first identifying strategies that work vs. strategies that don’t work to get their needs met. My son had them frequently for a period of 3-4 months. It was exhausting and frustrating, but perfectly and a normal part of the human development curve. The treatment strategy – smart parenting. Now, less confident parents will turn to a pill instead of a parenting manual to help their kids. Good grief!”

Drug companies look to profit from DSM-5
“The DSM-5’s changes widen the treatment potential for several mental problems, including depression, premenstrual symptoms, binge eating and dementia. Pharmaceutical experts expect that the DSM-5’s legitimization and expansion of certain disorders will pave the way for companies to develop and sell more drugs to treat them, and increase FDA support for new medications.” http://www.marketwatch.com/story/new-psych-manual-could-create-drug-windfalls-2013-06-05

Harriet L. MacMillan: “As a child psychiatrist and pediatrician practicing in the area of family violence, I welcome the increased focus on trauma-related and stressor-related disorders in DSM-5, which is reflected by several important changes.”

“The key changes for those of us working in the family violence field are as follows [2]. First, the move of PTSD and acute stress disorder away from Anxiety Disorders to a new stand-alone chapter Trauma- and Stressor-Related Disorders (TSRD), reflects the current deeper understanding of the heterogeneous symptom presentation of stress-related conditions.”

“It is encouraging to see the development of a new PTSD sub-type in DSM-5: Post-traumatic Stress Disorder for Children 6 Years and Younger. The DSM-IV PTSD criteria did not take into account the variation in symptom presentation during development, especially in young children.” http://www.biomedcentral.com/1741-7015/11/202

DSM-5: Diagnosing for Status and MoneyHere is a very interesting site whose “… primary goal … is to promote critical thinking in psychology and psychiatry by presenting a controversial critique of psychiatric diagnosis.”http://www.zurinstitute.com/dsmcritique.html#didnot

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23 Comments

The truth is there is no such thing as “normal.” There really are no completely mentally healthy people. This has always bothered me about my profession because it seems dishonest. There are however, varying levels of severity of mental illness, but eveyone has some degree. In the US acees to mental health care is a disgrace. If DSM labels more things as disorders then more people’s insurance companies will have to pay for therapy. But you are right, the whole premise is dishonest~ Love you blog! It brings up such important issues and I admire you too! ❤

Hi Mario,
Thanks for your interest. I don’t really use Twitter. You can follow my blog and receive notifications to your email address by clicking the Follow button (at the top, if you’re logged in, or in the lower right-hand corner if you don’t have a WP account).
Best,
Heila

I really have to say that I do not like labels. I think when you get to really know most people, you could give everyone some kind of mental illness diagnosis. We all have our weak and strong times and times when it’s just too much. We also know those that have very bad problems that usually don’t go away, voices, delusions. I believe that most politicians display delusions of grandeur and other gross ego problems that are supposed to be symptoms of mental illness. The truth is humanity as a whole is very flaky, that’s the nature of the beast. We have allowed others to label us and many times unfairly. It also depends on who is doing the judging of another as to that label. Good post!

Thank you dear Po’ Girl for reading and commenting. And liking! Yes, I agree re politicians’ delusions of grandeur and ego… I don’t trust most of them. And right, it depends on who is judging!! Our cultural and social backgrounds also have a huge impact on how we perceive behaviors and on how we deal with people who stand out, in one way or another.

Did you read it for professional reasons? Before my son was diagnosed with schizophrenia about two years ago I didn’t even know about the existence of this book. Fortunately, there are quite some good psychiatrists out there that don’t rely too much or solely on the DSM.

I meant to answer this a couple of times and then got distracted! It was required material for my class: Psychopathology and Counselling when I was in grad school. And I agree, you should not rely upon it solely.

Hi Ben, I was at a conference on schizophrenia in Tel Aviv yesterday and I can tell you, things are changing to the better. Slowly, maybe even VERY slowly depending on where you look, but changing. There is an increasing understanding that medication has to be limited and that mental disorders/problems require different/additional approaches:
“Finland Open Dialogue
A Finnish alternative to the traditional mental health system for people diagnosed with “psychoses” such as “schizophrenia” is “Open Dialogue.” This approach aims to support the individual’s network of family and friends, as well as respect the decision-making of the individual. ” http://www.mindfreedom.org/kb/mental-health-alternatives/finland-open-dialogue